ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
Extract:
Question 1 of 5
A nurse is providing an in service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
Correct Answer: A
Rationale: The correct answer is A. Evacuating a client who uses a wheelchair and is confused should be the priority because they have limited mobility and may not be able to self-evacuate safely. Confusion may lead to disorientation during an emergency, increasing the risk of harm. Additionally, wheelchair users may require assistance with moving downstairs or through narrow passageways.
Choice B is incorrect as a bedridden client wearing a hearing aid can still be safely evacuated with assistance.
Choice C is incorrect because an ambulatory client receiving oxygen can still walk and evacuate, although oxygen tanks should be taken into consideration.
Choice D is incorrect as a client in balance suspension traction may be stable and not in immediate danger compared to the wheelchair-bound and confused client.
Question 2 of 5
A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take.
Correct Answer: B, A, C, D
Rationale: B: Activating the facility's fire alarm system is crucial to alert other staff members and ensure the safety of all individuals in the building. A: Transporting the client to another area is necessary to move them away from the fire hazard. C: Closing windows and doors helps contain the fire and prevent it from spreading. D: Using the fire extinguisher should only be done if it's safe to do so and if the nurse has been trained in its proper use.
Choices E, F, and G are incorrect as they do not prioritize the immediate safety of the client and others in the building.
Question 3 of 5
A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions?
Correct Answer: A
Rationale: The correct answer is A: Shrugs his shoulders. Cranial nerve XI, also known as the spinal accessory nerve, innervates the trapezius and sternocleidomastoid muscles responsible for shoulder shrugging. By asking the client to shrug his shoulders against resistance, the nurse can assess the integrity of cranial nerve XI. Sticking the tongue out (choice
B) involves cranial nerve XII, frowning symmetrically (choice
C) involves cranial nerve VII, and identifying a sour taste (choice
D) involves cranial nerve IX and VII. These actions do not assess cranial nerve XI.
Question 4 of 5
A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following statements by the newly licensed nurse indicates an understanding of the procedure?
Correct Answer: A
Rationale: The correct answer is A: "I will hang a new bag of TPN and IV tubing every 24 hours." This statement indicates an understanding of the proper procedure for TPN administration. TPN solutions are typically changed every 24 hours to reduce the risk of bacterial contamination. By changing the TPN bag and tubing daily, the nurse is following best practice guidelines to maintain the sterility and integrity of the TPN infusion, ultimately reducing the risk of infection for the client.
Choices B, C, and D are incorrect:
B: "I will obtain the client's weight every other day." While monitoring the client's weight is important for assessing fluid status and nutritional needs, it is not directly related to the procedure of administering TPN.
C: "I will monitor the client's blood glucose level every 8 hours." Monitoring blood glucose levels is important in clients receiving TPN, but the frequency of monitoring can vary depending on the client's condition and the healthcare provider's orders. It
Extract:
Nurses' Notes
Day 1, 0915:
The client's adult child reports the client has not slept for 2 days and has become obsessed with cleaning the house and hosting parties. At times the client is overly joyous and has a very elevated sense of self-confidence. The adult child states that the client has also demonstrated very impulsive spending habits and expresses concern about the client giving away large sums of money to others.
The client's speech is very pressured, disorganized, and loud. Client unable to recall the last time they ate.
Day 1, 0930:
Client questioned about their hallucinations and states that the same person has been following them around inside and outside the house for days. Client asks the person what they want but never receives an answer. Client states that this person has never told them to do anything; they just stare and smile
Question 5 of 5
For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.
Correct Answer: A: Psychosis; B, C, D, E: Mania
Rationale: Hallucinations are typically associated with psychosis, where individuals experience sensory perceptions that are not real. Lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are hallmark features of mania, a state of elevated mood and energy often seen in bipolar disorder. These symptoms reflect the impulsivity, racing thoughts, and increased activity levels characteristic of manic episodes.
Therefore, the correct answer is A for psychosis and B, C, D, E for mania.